I've been a consultant urologist for the past 20 years. My particular contribution to urology has been as one of the worldwide pioneers of laparoscopic (keyhole) urology. This involves carrying out relatively major operations on patients without making a large wound. It has been a passion of mine for decades and I have a number of UK firsts under my belt in terms of procedures performed. Two years ago, I moved from laparoscopic to robotic surgery, so instead of the surgeon and his assistant holding the instruments and the camera this is done by a computer-controlled machine. Most of my practice is now related to prostate cancer, both in the outpatient clinic – where men with an elevated PSA or urinary symptoms can be treated – and in the operating theatre.
My main presence is at the London Bridge Hospital, but I have also worked at Princess Grace Hospital – both central London hospitals that are extremely well equipped. The particular facilities that I use at both hospitals are the surgical robots: the da Vinci Xi at London Bridge Hospital and the da Vinci Si at The Princess Grace Hospital. Both have MRI scanning, CT scanning, nuclear medicine and the latest diagnostics. The London Bridge Hospital also has an intensive care unit and frozen section analysis; in other words, it has the capability to enable the pathologist to examine tissue during the operation in order to maximise functional results without cost to the cancer control.
The main advance over the past 20 years has been in the sphere of minimal-access surgery – laparoscopic surgery and, more recently, robotic surgery. This has really changed patient outcomes, in particular for prostate cancer, in terms of continence and potency. Robotic surgery allows patients a completely different set of outcomes, much of which is due to the 3D vision and precisely controlled instrumentation.
The latest advances in prostate cancer surgery relate to a new approach called Retzius-sparing, which approaches the prostate gland from underneath the bladder rather than from above it, as is the case with conventional prostate surgery. The technique was initially developed in Milan, Italy, seven years ago and I was the first in the UK to use it in 2016. It almost completely guarantees that patients won’t experience any incontinence after prostate cancer surgery.
Although surgery is the most effective intervention for prostate cancer, in the past patients have understandably investigated alternatives – such as radiotherapy, high-intensity focused ultrasound, cryotherapy and focal therapy – because they have been concerned about the negative consequences of surgery, namely incontinence and impotence. Retzius-sparing prostatectomy addresses both of these concerns by leaving intact the anchor points for the continence mechanism at the front of the prostate and also by preserving arteries that are important for erections.
The operation is technically difficult to perform as it is done in a very confined space and this is where the robot is particularly useful by giving the surgeon a 30-degree up view that cannot be replicated by open surgery, together with motion-scaled and precise movements of the surgical instruments.
Out of approximately 3,000 keyhole prostate cancer surgeries, I've done 195 operations using the Retzius-sparing technique, which has completely transformed the continence outcomes. We have published the results of our first 40 cases, which showed that 97.5% of patients were socially continent (zero to one pad per day) and that 90% were totally continent at four weeks after surgery. This is three times better than the results seen in the past with conventional surgery done by the most experienced surgeons.
In terms of potency, one would expect that preserving more arteries going towards the penis will result in better potency than previously seen, but we need longer follow-up of patients to investigate this. So, it's a really exciting departure from an operation that has basically been done the same way ever since it was conceived more than 100 years ago, and the reason for that is the robot.
Typically, a patient having this surgery would be in hospital for one or two nights, have a catheter for nine days and be back to doing 90% of their normal activities within three weeks.
I think the next major advance will be the ability to fuse in real time the MRI scan image of the prostate, together with the location of the cancer, with the view that the surgeon has. This will allow even more accurate surgery and even better cancer and functional outcomes. There are a number of technical hurdles that need to be resolved first, but I believe that they will all be overcome within the next decade.
